Monday, October 13, 2014

University of Wisconsin 2nd Annual Update

I was in Madison Wisconsin for the Second Annual University
of Wisconsin Clinical Update. I reviewed
thefirst conference last year. For
anyone unfamiliar with the conference it started last year as a replacement for
the long running conference run by John Greist, MD and James “Jeff” Jefferson,
MD. They were acknowledged again this
year for their contributions to psychiatric education. This is a very good conference because it
builds on that tradition. The actual venue is the Monona Terrace Convention Center on the shore of Lake Monona. It is an excellent modern facility with only one drawback - they charge for high speed wireless access. I talked with
many psychiatrists there who had attended the previous conferences for a long
time. They bring in speakers who are
some of the top experts in their fields for in depth presentations and there is also a
strong department at Wisconsin headed by Ned Kalin, MD. The conference wraps up in in a day and a half and that seems like a very good length for working psychiatrists. Combine that with very accessible speakers and an excellent course
syllabus and it has what I consider to be the elements of a good educational
experience. The other bonus is that I
have never really seen an unbalanced presentation at this conference. The overarching message is that there are a
number of interventions, that treatment is successful, and that there is a
scientific basis for what psychiatrists do.

I thought I would make a few comments on day 1 and then move on to day 2.

The first lecture was given by Maria A. Oquendo, MD on the Neurobiology, Assessment, and Treatment of Suicidal Behavior. Aleman and Denys have called for the investigation of suicide as a special problem apart from any particular diagnosis. She began with a review of the epidemiology of suicide, including the fact that 90-95% of suicides have an psychiatric disorder. She also discussed the converse of that statement - the vast majority of patients with psychiatric disorders never attempt suicide. That statement is usually not discussed. It is a parallel argument to violence and aggression in psychiatric disorders. It has implications for any care based on dangerousness (threat of aggression or suicide). She presented an interesting stress diathesis model of suicidal behavior that takes into account clinical features (impulsivity, cognitive inflexibility, substance use, family history, poor social support) and neurobiological features (low serotonin, decreased noradrenergic (NA) neurotransmission, inflammatory markers). Her model links norepinephrine neurotransmission with pessimism. She cited evidence that included a slide of CRH innervation of NA neurons and behavioral models that lead to NA depletion in animals. She reviewed some of the evidence of inflammatory signaling related to childhood adversity, the mechanism of interferon-alpha induced depression and markers of inflammation in suicide attempters versus controls (increased interleukin- 6 (IL-6), tumor necrosis factor - alpha (TNF-alpha), elevated microglial cells, increased IL-4 in women, and increased IL-13 in men. The tentative conclusion is that suicide occurs in the context of a stress response or at least it appears to have the same neurobiology of a stress response. She concluded with a discussion of public health approaches to preventing suicide. She had no specific recommendations for how psychiatry fits into that response apart from presenting data that increased antidepressant prescriptions led to decreased suicide rates in Sweden, Hungary, Japan, and Slovenia. She also discussed specific psychotherapeutic interventions for suicide by name and presented a study of cognitive behavioral therapy that led to a 50% reduction in suicide attempts. Dr. Oquendo also provided an excellent contrast in how the results of observational studies, meta-analyses, and double blind placebo controlled studies can differ and what biases may be in effect. In the case of lithium preventing suicidal behavior, most clinicians are aware of the fact that only lithium and clozapine are consider medications that prevent suicide. In the case of lithium, it turns out that data is from observational studies and meta-analyses but not double blind placebo controlled trials. The two double blind studies do not suggest that lithium is more effective in preventing suicides than other agents. She suggested one bias may be a tendency of clinicians to use lithium in people who can use it more safely and that led to fewer suicide attempts.

I found the presentation on suicide and suicide assessment very interesting. It is such a broad topic that a single lecture has to pick a focus. The presentations on suicide that I have seen tend to focus on trying to figure out which people attempt suicide and interventions in those populations. People with psychosis and suicidal ideation – a common clinical scenario for psychiatrists are generally left out. It would definitely complicate the presentation
at a couple of levels. There is the
issue of what happens to the usual risk factor analysis, especially in the case
of subtle forms of psychosis. Factors
that are typically seen as reliable (deterrents to suicide, prevention plans) can
be thrown out in that situation since the patient has had a marked change in
their conscious state. That is true
whether or not the patient is clinically interviewed or given a structured
interview like the CCRS. In the case of
psychotic individuals paranoia is also a risk factor for suicidal
behavior. The paranoia is focused on a
particular situation where the individual believes that he or she will be
tortured or killed by someone. They
develop a plan to kill themselves rapidly using a highly lethal method before
that can happen. A common scenario is
to have a knife or handgun on the nightstand just in case it becomes
necessary. In both of these treatment
situations, the preferred course of treatment is to address both the depression
and psychosis at the same time. Past studies of these populations also suggest very high levels of hypothlamic-pituitary-adrenal (HPA) axis activation, consistent with Dr. Quendo's model.

Roger McIntyre, MD followed with Practical Considerations in the Successful Treatment of Bipolar Depression. There seems to be fairly widespread confusion about the diagnosis of bipolar disorder. I think it is common for consulting and subspecialty psychiatrists to reverse the diagnosis of bipolar disorder more often than they make new diagnosis. Dr. McIntyre made that point but said that misdiagnosis is still a problem even in an era of overdiagnosis. He took the assessment up a notch to discuss the utility and limitations of the
diagnostic issues of bipolar qualifiers in DSM-5 ( mixed features, anxious distress) and what
they imply for diagnosis and treatment.
He also emphasized the need for time to do an assessment. He appreciates the fact that primary care
physicians may have as little as 6 minutes to make a mood disorder diagnosis
but said that even in his specialty clinic he may not know the diagnosis of 25%
of the patient after doing a lengthy assessment. He made this point to
illustrate that in many patients a single cross sectional view of symptoms in a
clinic appointment is insufficient to make the correct diagnosis.

He presented an excellent graphic showing the DSM-5 continuum from manic to manic with mixed features to depressed with mixed features to depressed. He also spent a fair amount of time discussing the treatment of comorbid anxiety as a significant morbidity in bipolar disorder. He presented interesting data on how comorbid medical and psychiatric conditions in bipolar disorder were the rule rather than the exceptions. His main focus was on metabolic syndrome, obesity, and migraine headaches. He presented very good graphics on mechanisms associated with these comorbidities. He made the point that the metabolic abnormalities (much like studies done in patient with schizophrenia who had never been treated with medications) were associated with a number of social, metabolic, and environmental factors. He suggested that the obesity/major depression and obesity/bipolar disorder phenotypes carried specific risks including poor cognitive performance, anxiety symptoms, and in the case of depression a possible higher suicide risk. He cited estimates of metabolic syndrome ranging form 20-66% in populations with bipolar disorder compared to a general population estimate of 23.7% from the NHANES III study. He presented interesting data on the correlation between cognitive impairment in obese and overweight bipolar patients that can be demonstrated in first episode manic patients (obese versus non-obese). At the molecular level it has been demonstrated that there is a gradient of inflammatory markers between obese and non obese bipolar patients. He has a published paper that looks at the relationship between treatment response in depression and body weight. Although he did not speculate on an exact mechanism he suggested there were altered brain systems involved in cognition in many of these patients.

The section of Dr. MacIntyre's lecture included an interesting graphic that had all FDA and EMA (European Medicines Agency) approved medications for bipolar-manic, bipolar depressed, and maintenance therapy. Both agencies have approved quetiapine for bipolar and only the FDA has approved lurasidone and olanzapine-fluoxetine combination (OFC). The number of medications not approved in all columns is about the same (4 for EMA and 3 for FDA). He presented number needed to treat (NNT) and number needed to harm (NNH) analyses for OFC, quetiapine, and lurasidone and in that analysis lurasidone looked like the superior medication but that analysis is for specific side effects. The NNT was nearly identical for all medications. In terms of overall treatment he was in general agreement with the Florida Medicaid Drug Therapy management Algorithm. One of the very interesting points he made during his presentation was that treating and preventing recurrent manic episodes may reduce risk for Alzheimer's dementia but that is potentially confounded by the effect of lithium on GSK-3-induced tau phosphorylation.

Lithium Pearls (From several lectures)

1. The claim that lithium is one of two
medications that can prevent suicide is based on observational studies and meta-analyses. There have been two double blind studies
looking at this issue and they have both been negative.

2. Experts continue to use lithium and
consider it to be one of the major treatments for bipolar disorder. Lithium may provide more benefit to manic prone patients with
long periods of stability and a positive family history.

3. Once a day dosing was recommended.

4. Lithium can be used in pregnancy given
several specific precautions and informed consent issues; including
precautions are the time of delivery to prevent elevated lithium levels in
the newborn.

5. Lithium may decrease the risk of Alzheimer’s
Disease and minimal cognitive impairment.

After afternoon breakout sessions on various topics, the final presentation was by Ned Kalin, MD on the Neurobiology of Depression. As a point of disclosure I know Dr. Kalin and was his first fellow at the University of Wisconsin back in 1984 and I completed my residency there. He is a model of the clinical researcher who has seen patients his entire career and also been involved in basic science research. There were several other department members at Wisconsin engaged in the same balance of clinical and scientific activities. I learned that he was also President Elect of the Society of Biological Psychiatry. The UW has always been active in primate research and Dr. Kalin discussed some important ethical and scientific issues about basic science research in non-human primates including the reason for primate research and the changes in standards and research settings over the years. He has broadened his research over the years to include how depression and anxiety start in childhood and adolescence. He posted an interesting graphic on deaths worldwide due to violence that suggested suicide was the top cause, followed by homicide and then warfare. It was based on World Health Organization (WHO) data. He showed experimental data on conscious regulation of the amygdala. These interesting studies show that activity in the amygdala can be modulated by cognitive activity that either enhances of decreases the response to the feared stimulus. The ventromedial prefrontal cortex (vmPFC) and orbitofrontal cortex (OFC) are critical associated areas with activity correlating inversely with activity in the amygdala (high vmPFC and OFC activity correlate with low activity in the amygdala). Preliminary data suggests that depressed patients fail to suppress activity in the amygdala with vmPFC and OFC activity. A similar change occurs in the ventral striatum when depressed individuals attempt to enhance their positive affect over the course of an imaging session. Controls show a significant increase in left nucleus accumbens activity (LNAcc).

Dr. Kalin reviewed the genetics and environmental factors in depression using a graphic that cited 3 of Kendler's papers. He reviewed the progression of hypotheses ranging from monoamine depletion to altered serotonin neurotransmission to serotonin alteration hypothesis to stress diathesis to neurotoxins to inflammatory/cytokine theories. One of the possibilities he discussed was a theory that at least some developmentally based depressions are based on frontal cortical-amygdala substrates that result in increased activity in the amygdala and associated neuroplasticity mechanisms that also lead to increased vulnerability. Cognitive therapy for depression may strengthen the ability of the frontal cortex to regulate the amygdala. One of his areas of intensive investigation has bee the HPA axis and its effect in depression. He reviewed the important roles of CRF both as an endocrine modulator and a neurotransmitter. He used a Vonnegut quote from Breakfast of Champions as a quick review of HPA axis physiology. For anyone who had read the book (and forgotten some physiology) it was an interesting reference. In the last quarter of the lecture he reviewed the issue of stress in separated infants, maternal stress, and adults in human and non-human primates. The focus was primarily on neuroanatomy, neuropathology, neuroendocrinology and possible treatments that target these systems. Earlier in his discussion he also posted a graphic on translational neuroscience and how neuroscience findings need to be able to correlate at the clinical level. A detailed discussion of that approach is available in this article that is available online at no cost.

The first day in Madison went as well as expected. Lectures with very high quality content by researcher-clinicians who actually see patients and investigate clinically relevant topics. Psychiatry taught, researched, thought about, and practiced the way it should be.

Supplementary 1: I thought it was very interesting that we are still talking about lithium as a very effective medication for psychiatric disorders int he same city that hosted the Lithium Information Center cofounded by Greist and Jefferson and the same location where the Lithium Encyclopedia for Clinical Practice was published.

2 comments:

Just a quick comment on lithium and suicide: the evidence seems to be that lithium does robustly prevent completed suicide while having little effect on so-called parasuicidal behaviors. Here is a good summary review by Allan Young of Serretti’s meta-analysis: http://ebmh.bmj.com/content/16/4/112.long